John P. Cunha, DO, FACOEP

John P. Cunha, DO, is a U.S. board-certified Emergency Medicine Physician. Dr. Cunha's educational background includes a BS in Biology from Rutgers, the State University of New Jersey, and a DO from the Kansas City University of Medicine and Biosciences in Kansas City, MO. He completed residency training in Emergency Medicine at Newark Beth Israel Medical Center in Newark, New Jersey.

Prostate cancer biopsy

The result of the pathologist's analysis of the biopsy cores under the microscope is the only way to diagnose prostate cancer. The biopsy procedure is not perfect, and cancer present in the prostate may be missed. If the urologist is still suspicious based on the results of the examination and the ultrasound images seen during the procedure, additional biopsies may be recommended.

The pathologist's report on the biopsies showing prostate cancer will contain much detailed information. The size of the biopsy core and the percentage of involvement of each core will be reported. Most importantly the prostate cancer present will be assigned a numerical score, which is usually expressed as a sum of two numbers (for example, 3 + 4) and is referred to as the Gleason Score. This characterizes the cancer and helps predict its likely level of aggressiveness in the body. It is often also referred to as the grade of the prostate cancer.

The Gleason score and the extent of involvement of the biopsy core expressed as a percentage, as well as the PSA level as well as your general state of health and otherwise estimated life expectancy all help the doctors make their best recommendations for you regarding how your cancer should be treated.

The accuracy of the PSA test

The PSA test is a tool for use by your doctor but it is not a perfect way to tell whether or not a patient has prostate cancer because is not sensitive enough to pick up all prostate cancers. It is not specific enough in that it may be elevated in people without prostate cancer, such as those whose prostate glands are infected, or just inflamed, but not cancerous. It is also elevated for days after a digital rectal exam, or after ejaculation. Nevertheless, it accurately measures the amount of PSA in the blood.

The interpretation of the PSA result must be done with care. PSA results must be, for example, interpreted in the context of the patient's age. Younger men (under 70, and definitely under 60) may have either more aggressive prostate cancers, or more life to lose if not evaluated aggressively. Conversely, men over 70 often have more indolent or slow-moving prostate cancers, or other medical conditions which may be greater threats to their lives over the next 10 years than may prostate cancer, and thus less aggressive evaluation and treatment may be warranted. The test is best used to establish a pattern in a man with serial measurements obtained over years.

Doctors probably only find the more aggressive prostate cancers. The disease is common as men age. It is estimated 16% of men will be diagnosed with prostate cancer in their lifetime and yet only 3% will die of it. Many men likely have small prostate cancers present by the time they are over 60 years of age, with estimates ranging from 30% to 40% having prostate cancer cells in their prostates. The presence of these small cancers also likely further increases with age. Most of these cancers are very slow-growing and not aggressive in their tendency to spread as they are never discovered or symptomatic during the men's lives. Diagnosing these prostate cancers may only increase the cost and result in treatment-related complications in these men.

Talk to your doctor about the risks and benefits of having PSA testing if you are 40 years of age with a family history of prostate cancer (or age 50 if you do not have a family history), or are of African American ancestry. The test results should be considered in the context of the man's urinary symptoms, if any, his family history, his race and ethnicity, his diet, weight, and physical findings. Further there should be attention given to the pattern of change in his serial PSA measurements.

Numerous different ways to refine the use of PSA testing have been attempted. Some of these include evaluations of the:

PSA doubling time, which refers to how long it has taken for the PSA to double.

PSA velocity, which looks at how rapidly the PSA values have changed over time.

PSA density, which looks at the PSA result and considers the prostate gland volume as
determined on ultrasound evaluation.

PSA fractionation, which is another test that measures the amount of free PSA versus protein-bound PSA in the bloodstream. The lower the percentage of free PSA, the higher the risk of cancer.

In patients with prostate cancer whose PSA was initially elevated, the PSA is an excellent tool to assist in care and follow up both during and after treatment.